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Corneal sealant has application in complex surgeries
In some cases the sealant may reduce OR time and enhance wound closure.
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Clear corneal wound architecture has been largely perfected for simple surgical procedures such as uncomplicated cataract removal. Typically, these incisions require minimal manipulation and result in wounds with few reported adverse effects and only the occasional need for sutures or other intervention. However, for more complex surgical procedures, wounds are not always self-sealing due to a combination of factors such as more wound manipulation and larger or multiple incisions.
Compromised wound integrity is attributable to a number of factors, and even perfectly constructed wounds are subject to the effects of internal and external pressure or manipulation. While wound size plays a role in the ability of the incision to seal, the level of manipulation is the key indicator of how well a wound will heal. In addition, there are challenges and forces that could be encountered after surgery, including external manipulation, which may allow fluid into or out of the incision.
Advancements in wound closure technology have given surgeons options to use in addition to the traditional suture; however, until recently, none have been approved specifically for use in the eye. The ReSure Sealant (Ocular Therapeutix) is an FDA-approved polyethylene glycol hydrogel that offers excellent eye adherence and naturally sloughs off in the tears and during re-epithelialization. This is a viable alternative to earlier glue predecessors, which have not been well tolerated on the eye.
Leak prevention
Leak prevention is important for patient comfort and satisfaction. Failing to stop or prevent wound leakage may result in sight-threatening events or compromised refractive outcomes, such as hypotony, corneal decompensation or epithelial downgrowth, or may subject IOLs to movement due to instability of the capsular bag.
These issues are of particular concern in complex anterior segment surgeries, eyes with previous surgery and glaucoma surgery. Tissues may be more friable, and even sutures may create needle tract leakage. This is where a sealant may be a potential adjunct or alternative to sutures.
As a glaucoma and complex eye surgeon, I perform a significant number of trabeculectomies. Although my traditional approach to wound closure is suturing, I still find that up to 10% of cases have some degree of early postoperative wound leakage, and in a training environment, that number can go even higher.
Images: Ahmed IIK
I have experience in using the ReSure Sealant in higher-risk eyes and apply it as an adjunct to sutures. My typical technique for trabeculectomy involves making a fornix-based flap and suturing at the limbus with a 9-0 Vicryl suture. I then apply the sealant right over the conjunctival closure. For more complex surgeries such as IOL dislocations and exchanges, which often involve large incisions, previous incisions or extra manipulation, I also apply the sealant right over the top of sutures or skip the sutures altogether. Thus far, I have been pleased with the enhanced wound security in these types of cases.
Additionally, I have used the sealant for early postoperative wound leaks in conjunction with a bandage contact lens, which prolongs the effect of the product. I have done this in the setting of recent bleb surgery or complex intraocular surgery with success.
Reducing sutures
Traditionally considered the gold standard, sutures come with disadvantages including inflicting trauma on the cornea; creating a possible nidus for infection, inflammation, and neovascularization; inducing corneal astigmatism; and requiring an additional office visit for removal. In complex intraocular procedures in which I would normally use multiple sutures, I have been able to either reduce or eliminate the need for sutures due to the added security of the sealant.
Value
Ophthalmological surgeons have become adept at corneal incisions for cataract surgery. When cost is a factor, we must evaluate whether the suture or sealant step is necessary. In situations in which we are able to actually skip the suturing due to the use of a sealant, there is likely a benefit to the reduced OR time and extra cost of the suture material. This is also well tolerated by patients, and when used in trabeculectomy, they often find it less irritating when the sutures are covered by the sealant.
There are times when the tissue tension needs to be directed and the sealant does not have the tensile strength to hold the tissue. In those cases, suture closure is required.
Easy to use
Technique nuances are critical, and there is a short learning curve to apply the sealant expeditiously to prevent polymerization before fully covering the wound. Developing a cadence to achieve the right timing is the key. The trick is to mix it in 5 seconds, apply it and be off the eye within 11 to 12 seconds. If excessive sealant is applied, the patient may complain of foreign body sensation. However, the excess can be manually removed with a Weck-Cel sponge. Additionally, two applications of the sealant are available per unit if there is a need for a second application.
Conclusion
There appears to be little clinical downside to adding the ReSure Sealant as part of wound closure. This is particularly valuable in more complex anterior segment surgery. Added cost is certainly the most significant issue and question. As experience is evolving with this product, cost-effectiveness will need to be evaluated to determine which type of cases would be most likely to benefit from the use of a sealant. In some of my complex and glaucoma surgeries, the use of this sealant has reduced OR time and enhanced wound closure.
- Reference:
- Al-Mahmood AM, et al. Middle East Afr J Ophthalmol. 2014;doi:10.4103/0974-9233.124084.
- For more information:
- Iqbal Ike K. Ahmed, MD, FRCSC, can be reached at Credit Valley EyeCare, 3200 Erin Mills Parkway, Unit 1, Mississauga, Ontario L5L 1W8 Canada; email: ike.ahmed@utoronto.ca.
Disclosure: Ahmed reports no relevant financial disclosures.